Knowledge and practices related to snakebite prevention, China: a cross-sectional study

Abstract Objective To assess knowledge and practices related to snakebite prevention among Chinese residents. Methods By using a multistage random sampling approach augmented by snowball sampling, we surveyed residents from 10 provinces, one municipality and one autonomous region south of the Yangtze River Basin between May 2022 and February 2023. We supplemented the data with a national online survey. We used a χ2-test to identify differences in knowledge and behaviour across various demographic characteristics. We conducted multifactor logistic regression analyses to evaluate factors potentially influencing snakebite knowledge and practices. Findings We obtained 55 775 valid survey responses, 16 200 respondents from the face-to-face survey and 39 575 respondents from the online survey. Only 25.7% (14 325) respondents demonstrated adequate knowledge about snakebites whereas 25.6% (14 295) respondents knew basic first-aid practices or preventive behaviours. Age, marital status, educational attainment, occupation, type of residence and frequency of exposure to nature are significant independent variables affecting snakebite knowledge (P-values: < 0.05). On the other hand, gender, age, marital status, educational attainment, occupation and type of residence were significant independent variables affecting the behaviour of snakebite prevention and first aid (P-values: < 0.05). Conclusion There is a notable shortfall in knowledge, first aid and preventive behaviours among Chinese residents regarding snakebites. Misguided first aid practices can severely compromise the effectiveness of evidence-based therapeutic interventions. Consequently, improving health education concerning snakes and snakebites in this population is needed.


Introduction
Snakebite envenoming is an important public health problem in low-and middle-income tropical countries.Venomous snakebites can cause serious local and systemic symptoms, such as tissue damage, systemic muscular toxicity, systemic bleeding, acute kidney injury and death. 1,2The World Health Organization (WHO) recommends that snakebite be defined as a neglected environmental and occupational disease. 1,3pproximately 7400 people are bitten by snakes every day, resulting in 81 000 to 138 000 deaths per year and 400 000 people with permanent physical or mental disabilities. 4,5][8] In China, a large number of people working in agriculture, forestry and fisheries are at the risk of snakebite because these workers spend most of their time outdoors and are more likely to have regular interaction with snakes.In the country, there are an estimated 210 different species of snakes, with more than 60 species of venomous snakes and more than 10 species of highly venomous snakes.These highly venomous snakes are classified into: (i) neurotoxic; (ii) haematotoxic; (iii) cytotoxic; and (iv) mixed-venomous snakes. 8Previous studies indicate that if individuals have basic knowledge of snakebite prevention and first aid, the risk of being bitten as well as the risk of complications, disability and death may be reduced. 9tudies conducted in Brazil, India and Myanmar demonstrate a lack of knowledge about snakes and snakebite prevention and appropriate first-aid behaviour among the local populations.1][12] In India, one study found that 65.0% (13/20) of schoolteachers surveyed lack basic knowledge about snakes and snakebites. 11e conducted a cross-sectional study to understand current knowledge and practices related to snakes and snakebite among Chinese people, especially residing in the vicinity of the southern Yangtze River Basin.The purpose of our study is to provide evidence for relevant departments in China to formulate policies and protocols for health education.

Methods
We conducted a cross-sectional study in the vicinity of the southern Yangtze River Basin, China, from May 2022 to February 2023 using multistage random and snowball sampling to obtain our study sample.Based on a literature review and our combined work practice, we selected 10 provinces (Fujian, Guangdong, Guizhou, Hainan, Hubei, Hunan, Jiangxi, Sichuan, Yunnan and Zhejiang), one municipality (Chongqing) and one autonomous region (Guangxi) with known incidents of severe snakebites.We used the convenience sampling method to select three cities from each province, municipality and autonomous region: three districts or counties from each city, and three villages from each district or county for a total of 324 residential areas.
We conducted a survey with between 30 and 50 residents from each community or village using the chance encounter or convenience sampling method.Where literacy levels were low, we provided oral questionnaires.Literate residents self-filled the survey form and returned them to project enumerators.All surveys were distributed and collected face-to-face at the village level.At the same time, we used the instant message software WeChat (Shenzhen Tencent Computer System Co., Ltd, Shenzhen, China) and Tencent QQ (Shenzhen Tencent Computer System Co., Ltd, Shenzhen, China) to show advertisements or pop-up invitations in other regions to recruit random residents to participate in the same online survey we used in the villages.
This study was approved by the medical ethics committee of Hainan Medical University (ethics number: HYLL-2022-226), and informed consent was obtained from each participant before completing the survey or questionnaire.The preface of the survey or questionnaire explained the purpose of the study, and all data were collected without recording any identifying data except for gender, i.e. male or female.

Questionnaire design and measurement
We designed our survey based on a combination of literature review, expert consensus on snakebite, interviews with experts and focus group discussions.In addition, a pre-survey was conducted in three cities of Hainan province to assess the validity of the survey and make any necessary changes or improvements.We designed the survey to assess overall knowledge of snakes and snakebite prevention and first aid.The survey included topics on demographic characteristics, snakebite-related knowledge and experience, and snakebite prevention and first-aid behaviour.A translated version of the questionnaire is available in our online repository. 13

Quality Control
We designed our online survey using Questionnaire Star (Question Star, Hanover, Germany), which provided us with a weblink that we sent to participants using advertisements and popups to participate via QQ and WeChat.All participants were assigned a unique identifier while completing the online survey to prevent repeat submissions.

Statistical Analysis
We collated all data into Microsoft Excel (Microsoft, Redmond, United States of America) and imported it into Questionnaire Star platform.The data were analysed using SPSS, version 25.0 (IBM, Chicago, USA).The knowledge survey consisted of 10 multiple-choice proficiency questions.Each question had four possible correct answers.Scores ranged between 0 and 4 for each question for a total possible points of 40.Each question also contained the option "I do not know" as a possible response.Choosing "I do not know" resulted in a score of 0 points.If the total score of a participant was 20 points or less, we considered the participant as having limited knowledge, and we considered a participant with a total score of 21 or above (greater than 50% correct) as having sufficient knowledge.
The practices section consisted of five multiple-choice questions, of which one question contained only incorrect answers as options.Each question also contained the option "I do not know", and the scoring method was the same as that of the knowledge section described above.Questions with no correct answers were counted as zero in the total score; and the total score for the behavioural component was 16 points.If the total score of a participant was 8 points or less, we considered the participant to have limited knowledge, and if the participant had a score of 9 points or more (greater than 50% correct), we considered them as having sufficient knowledge.
We used univariate χ 2 -tests to evaluate variables for inclusion in multivariate analyses.Statistically significant variables in the univariate analysis were taken as independent variables, and knowledge and practices (converted into binomial data as limited knowledge: 0; sufficient knowledge: 1) were taken as dependent variables.We then used a multifactor logistic regression model to assess demographic and social factors associated with knowledge and practices related to snakebite among the participants.To do this, we used binary logistic regression where a P-value of < 0.05 was considered statistically significant.
Of the 55 775 respondents, a total of 14 325 (25.7%) had basic knowledge and 41 450 (74.3%) did not.Respondents with different gender, age, marital status, education level, occupation, residence type and high exposure risk exhibited statistically significant differences in knowledge (P-value: < 0.01; Table 2).Among the participants, 14 295 (25.6%) demonstrated knowledge of preventive and first aid behaviour whereas 41 480 (74.4%) did not.There were significant differences in knowledge regarding prevention and first aid behaviour among respon-  2).
Table 3 presents data on antivenom knowledge and first aid practices.For example, 55.5% (30 933/55 775) of respondents were aware of the existence of antivenom.We also identified numerous incorrect first aid practices among respondents, for example: rinsing the wound with liquids such as soapy water, alcohol, vinegar, or soy sauce; smearing the wound with toothpaste; cauterizing the wound; cupping or syringing the wound; tourniquet above the wound; or emergency treatments with folk remedies, among others.

Basic knowledge
Our multifactor logistic regression model indicates that individuals aged between 18 and 60 years had better basic knowledge about snakebite than those individuals younger than 18 years.Married individuals had more knowledge than all other groups (Table 4).Compared to individuals without any formal education, individuals partially educated at a primary level were found to have better basic understanding of information about snakes and snakebite prevention and first aid.
Snake catchers or breeders, and land and sea field operators had higher odds of knowing about snakes and snakebite than farmers: odds ratio (OR): 1.424 (95% CI: 1.189-1.707)and OR: 1.830 (95% CI: 1.505-2.226),respectively.Those who spend more time in the nature had better basic knowledge than those who did not: OR: 1.400 (95% CI: 1.339-1.464;Table 4).

Prevention and first aid
Our multifactor logistic regression model shows that females (OR: 1.305; 95% CI: 1.251-1.360)score higher in prevention and first aid practices than males.The cohort between 18-60 years old exhibited a broader understanding than their counterparts younger than 18 years.Being married and having some form of higher education suggested one had better preventive and first aid-related practices than uneducated and not married respondents (Table 4).

Discussion
Our results show that only one quarter of respondents had basic knowledge about snakes and snakebite, which is lower than reported results (35%) from a study of 100 respondents in India. 11Furthermore, only one quarter of residents had basic knowledge of prevention and first aid practices for snakebite, which is lower than reported results for India (64.2% of 227 respondents) and Myanmar (39% of 4276 respondents). 12,15Another recent study from China also highlights the need to improve residents' knowledge of snakebite first aid and prevention. 9n 2019, WHO released Snakebite envenoming: a strategy for prevention and control, a document which established numerous prevention and control strategies designed to halve mortality and disability rates related to snakebite by 2030. 168][19] The results of a pilot survey in India showed that only 21.0% of the 100 participants surveyed knew the type of antivenoms used in India; 11 compared to 87.6% (148/176) of participants in Sri Lanka, who were aware of the existence of antivenom and which hospitals stocked it in case of emergency. 20This result may be due to several factors, such as early research programmes in 1965 to study snakebite in Sri Lanka; 21 20 In China, we found that only 55.5% of respondents were aware of the existence of antivenom; let alone where to access it in an emergency.
3][24] Using the wrong first aid method to treat a snakebite not only costs valuable time but also increases the risk of complications or death for the patient. 25,26However, in our survey results, basic knowledge of preventive and first aid practices is low.The results may be due to the fact that individuals do not give enough attention to snakebite-related illness or injury, believing that the possibility of being bitten by poisonous snakes is minimal and will not lead to serious consequences; 16 or these results may be due to limited effective health guidance.For example, evidence for strapping or bandaging varies.One study in Nigeria showed that strapping may cause severe local swelling, negatively affecting the outcome of later treatments. 25In cases of extreme neurotoxicity, evidence suggests that strapping or bandaging is a recommended first aid method. 8,279][30][31] Therefore, teaching individuals correct prevention and first aid practices for different types of snakebite prevalent in their local area is necessary to reduce human morbidity and mortality from snakebite envenoming.
Our analysis suggests that a higher proportion of women have preventive and first aid knowledge than men.This outcome may be because women have a stronger fear of snakes than men, 32 so they are more likely to learn about and adopt snakebite prevention and first aid practices.Respondents older than 60 years had the lowest scores.In China, the belief that snakes selectively bite only those who are morally corrupt, coupled with the idea that various snake species symbolize either positive or negative

Research
omens, is a widely held superstition.This misconception often overlooks the medical significance of snakebite.
Reports suggest that such beliefs are also prevalent in India. 31,33,34arried residents tend to be better informed and exhibit more appropriate snakebite prevention and first aid practices.In contrast, those who are unmarried, divorced or widowed may not have a spouse to communicate such knowledge, potentially resulting in less access to information compared to their married counterparts. 35Additionally, we found that the higher an individual's level of education, the more proficient they are in their knowledge and first aid practices about snakebite.This outcome may be, for example, because educated individuals have access to a wider range of information sources, such as magazines, social media platforms and educational websites, coupled with a greater capacity to assimilate knowledge and information about snakebite.
In India, rural residents with limited literacy obtain snakebite knowledge primarily from their immediate social circle and environment. 11Yet, this practice is problematic if the social circle possesses limited knowledge as well. 36or risk occupations, like snake catchers or breeders, there is foundational knowledge about snakebite due to the nature of their work.However, our study found that this career advantage does not substantially translate to better prevention or first aid knowledge, potentially due to the small sample size of such professionals.Our study has other limitations.The snakebite knowledge and behaviour questions could have been inadequate and lacked applicability across diverse geographic populations, misrepresenting participants' actual understanding of the concepts.Second, as this was a cross-sectional study, cause and effect could not be determined and recall bias could not be avoided.
One advantage of our study is that it reports on multiple demographic and social factors influencing snakebite knowledge and behaviour across 12 provinces and cities in China.We also supplemented the data obtained from face-to-face surveys with online surveys directed to WeChat and QQ users across the country.Given China's large population size (> 1 billion), drawing from national data can enhance statistical power.
To improve knowledge, educational sessions on snakebite, including lectures and video documentaries could be provided in public schools in high-risk areas, as done in a study from India.The sessions in this study were accompanied by interactive question and answer sessions and distribution of informative leaflets, with students being encouraged to share the information with their families, friends and neighbours. 14such approaches are deemed effective because schools are pivotal for health education activities, 37 and new media channels are an efficient means to spread health education programmes more broadly. 38,39nother Indian study found that over 85.0% of 413 participants demonstrated high retention of information even 12 months after training. 14Our study indicates that farmers with low education levels have poor knowledge of snakebite; prior studies suggest that digital media platforms and situational simulations could significantly enhance learning in these demographics. 40oth WHO and research from India and Nepal highlight the critical role of community health workers, educators and local officials in raising awareness about snakebite via radio, leaflets, post-ers and educational sessions. 14,16,41][43][44] Consequently, we suggest that relevant departments should increase funding for such research projects, and support scientific research and community intervention programmes tailored to the population's needs.
the high level of education, and residents' good understanding : We used a χ 2 -test to calculate statistical significance between the different groups.Inconsistencies arise in some final values due to rounding.

of the following is a first aid practice after a snakebite?
14Indicates incorrect first aid practice.Note:These questions are based on Chinese expert consensus on snakebite8and related studies in India,14as well as the design after group discussions and expert interviews.Bull World Health Organ 2024;102:234-243| doi: http://dx.doi.org/10.2471/BLT.23.290169Lanfen He et al. Snakbite knowledge and practices, China of snakebite.